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Hawaii's Need 



OF 



Medical Inspection 



IN 



Schools 




C -"- • ^ 



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Compulsory Medical Inspection of Schools, 

A PLEA FOR THE CHILD. 



W. H. Babbitt, 
Superintendent of Public Instruction. 

Long before the time of Ponce de Leon and his futile search 
for the phantom fountain of youth, were men endeavoring to 
find a specific for the ravages of time and a "cure-all" for ail- 
ments in old age, many due to neglect in youth. That we 
have all this time been missing the obviously correct source 
of a healthy old age as well as a preventive to a premature one 
may be putting the case too strongly ; but the light of scientific 
investigation shows conclusively that too little attention has 
been paid to youth in a preparation for maturity, and there 
is incontrovertible proof that most of the illiteracy, truancy 
and subsequent crime among the young is directly traceable 
to known, and oftener unknown, though easily remediable, 
defects in school children. Physicians and educators in some 
of our large centers have worked out a plan to overcome thes'^. 
defects in training the child, with results already promising 
great success and indicating that a path to health in old age, 
too long neglected, is to be given a fair trial. 

*'A sound mind in a sound body" has long been a favorite 
maxim with us but we have given undue emphasis to the 
sound mind to the lamentable neglect of the body. Many a 
parent complaining that his child is not being properly edu- 
cated would be well nigh staggered to know that his own 
ignorance and neglect have rendered his child physically un- 
able to receive a proper education. 

In 1905, there were 300,000 blind people in the United States, 
many of whom would never have become so had their defects 
received attention during school life. It cost the public some 
$15,000,000 to care for them. Evidence collected shows that 
from twenty to twenty-five per cent, of school children in the 
country, and about thirty per cent, in the cities, are defective 
in sight, and approximately five per cent, defective in hearing. 
In London, out of 8,000 children examined for vision, 60% 
were found defective ; in Minneapolis, out of 25,696, 32% were 
found defective ; in N,ew York, out of 55,332, 29.6% ; in Phila- 
delphia, out of 200,000, 28.4%; in Cleveland, out of 30,045, 



2 

20.7%. I^ ^ small minority of cases were such defects known 
to parents, teachers, or the children themselves. A local appli- 
cation may not be out of place. Somewhat over a year ago 
word reached me that a child in one of our city schools had 
been severely whipped and I was asked to look into the case. 
The teacher admitted whipping the child for inattentiveness 
and failure to obey orders. A careful inquiry developed the 
fact that the child was almost totally deaf in the. right ear and 
that when spoken to from that side she either did not hear at 
all or so indistinctly as not to comprehend what was said. 
The condition was unknown to parent, teacher and child. 
Hawaii has over 18,000 public school children. An examina- 
tion here would doubtless produce startling results. For the 
year ending April 30, 1908, the government dispensary gave 
4,605 treatments for trachoma to children from only twelve 
of our public schools in this city. How many private treat- 
ments were given, and how many in other places needed treat- 
ment, I do not know. 

Massachusetts has developed a system for testing sight and 
hearing, which may be applied by the teachers themselves, 
and the result of one year's work proved its value. Three 
hundred and forty-nine towns reported 432,937 children exam- 
ined, with 96,609 or 22% defective in sight and 27,387, or 6% 
defective in hearing. Physicians state that teachers properly 
instructed can discover from 75 to 85 per cent, of cases need- 
ing attention. The simplicity and effectiveness of the Massa- 
chusetts system commend it for adoption here. Exhibit No. 
I shows this system in detail. The cuts of the boy on Card 
No. 2 are a fair sample of results which may be reasonably 
expected where treatment is given. The above tests are ones 
involving a minimum of time and expense with promise of 
an unlimited amount of resultant good. Such tests, with 
arrangements made for furnishing glasses or medical attention 
at moderate cost to those who could pay, and assistance to 
those who could not, would remove one great obstacle to the 
proper development of the child. 

The primary object of medical inspection in schools was the 
detection of infectious and contagious diseases and the exclu- 
sion of pupils likely to spread same. An elaborate plan of 
inspection was adopted in New York City. Children having 
diphtheria, measles, scarlet fever, chicken pox, whooping 
cough, mumps, acute catarrhal infection of the nose or throat, 
pediculosis, contagious eye or skin diseases, w^ere sent home. 
In the first month, 10,567 children were excluded from school 
attendance. Realizing at once the seriousness of such a con- 
dition, the departments of Health and Education cooperating, 
adopted a scheme whereby children with minor contagious 



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3 

diseases, including pediculosis, eye and skin diseases, might 
remain in school if undergoing persistent and continuous treat- 
ment. This was rendered possible and safe through the ap- 
pointment of school nurses who gave minor treatments at 
school and visited the homes. As a result 98% of the children 
who would otherwise have been excluded were enabled to 
remain without danger of exposing others. New York's gen- 
eral system of records and notifications is indicated on Card 
No. 2. There is a supervising nurse having general charge of 
all nurses, who must be trained. A nurse is assigned to a 
group of schools which she visits each day at a specific time. 
In a special room or portion of the hall screened off, are 
referred to her all children suspected by the teacher of needing 
any attention. Minor treatments may be given by her and 
directions for home treatment. Careful individual records are 
kept. Cases showing symptoms of diphtheria, scarlet 'fever, 
measles, whooping cough, chicken pox, or mumps, are ex- 
cluded and the inspector notified. The nurse makes weekly 
inspection of the eyelids, hair, skin and throat of each pupil. 
She also visits the homes and shows how to treat and en- 
courages persistent treatment. Medical inspectors, all physi- 
cians, visit each school once a day and examine privately : 

1st. All children isolated as being suspected of having con- 
tagious diseases ; 

2nd. All children who have been absent from school ; 

3rd. All children returning after previous exclusion; 

4th. All children previously under treatment ; 

5th. All children referred to them by the school nurse for 
diagnosis ; 

6th. All children affected showing no signs of treatment. 

The medical inspector gives no treatment whatever but noti- 
fies the parents of defects and necessity for treatment and 
follows up each case to see that treatment is given. The 
homes of absentees are visited where sickness is suspected. 
At the beginning of each term the medical inspector examines 
the eyelids, throat, skin and hair of each pupil but without 
touching them, as shown by the photograph on card No. 2. 
In 1905, New York still further elaborated its plan and now 
makes a complete physical examination of each child, as indi- 
cated on the physical record card shown on exhibit No. 2, and 
the parents are notified of any defects. From ^larch 27th to 
December 23rd, 1905, 55,332 children were examined and 
33^551 cases of treatment found necessary. Their system, 
however, reduced absenteeism from 65,294 in 1903 to 18,844 
in 1905. 



4 

Does Hawaii need any such system? The following may 
be a partial answer. During the last twelve months the fol- 
lowing treatments were given at the dispensary for children 
from only 12 of our city schools: Tonsilitis, 2; asthma, 12; 
bronchitis, 10; scabies, 18; mumps, 24; eczema, 6; cough, 59; 
heart trouble, 20; toothache, 25; extraction, 65; boils, 17; 
styes, 19; earache, 20, and 41 other causes necessitating 658 
treatments. 

It is today an almost universally admitted fact that back- 
wardness, waywardness, truancy, degeneracy and crime in the 
young are in a large majority of cases traceable to some 
physical defect, and that the eradication of such defect tends 
to change the whole life history of the child. Examples with- 
out number might be given. In the Middlesex County Truant 
School, 61 out of 62 boys were found to have physical defects. 
In the Disciplinary School of Saginaw, Michigan, every pupil 
had defect of sight, or hearing, or both. In our own Boys' 
Industrial School, a medical inspection about a year ago, 
showed a number of aggravated cases. It is a noteworthy 
fact that without inspection and correction defects increase 
rather than decrease during school life, and that many a child 
leaves school more poorly fitted for life's work than when he 
entered. Is it not reasonable to believe, with the amount of 
accumulated evidence from all over the world, that if a proper 
system of medical inspection were introduced into our Hawai- 
ian Educational system the next generation and succeeding 
ones would produce better students and better physically 
equipped citizens, and that any sums expended would be more 
than compensated for by increased intelligence and greatly 
lessened tendency to crime? 

Much criticism is made of the present day methods of grad- 
ing children; that the good and bad, the sub-normal and the 
precocious, are made to mingle indiscriminately because of an 
age standard of grading. The department of Child Study and 
Pedagogic Investigation in Chicago has, since 1899, been mak- 
ing an exhaustive study of this subject. It takes up such 
topics as 

1. The physical differences of children in the same room; 

2. The physical power of the child during the school day ; 

3. The educational merits of different courses; 

4. The comparative value of full and half day sessions for 
young children ; 

5. The backward child and the truant ; 

6. The ungraded school room. 

It makes phycho-physical examinations of children to deter- 
mine why they are forward or backward, what reasons render 



them capable in some subjects and incapable in others, and 
suggests special schools or special courses for the correction 
of faults or the proper advancement of the child. Such a 
department here could render invaluable service. With our 
children of all nationalities, from all sorts and conditions of 
homes, with harmful as well as helpful inherited tendencies, 
with our different climatic conditions and our shifting popula- 
tion, with the unfortunate though unavoidable lack of train- 
ing along this line of most of our teachers, the advantages of 
such a department here are self-evident. The development of 
the child based on his physiological rather than his chronolog- 
ical age is going to have more and more consideration, and no 
where could such a study be more profitable than here. The 
relation of mentality to weight, height, strength and puberty 
is an important one and the proper grading of the child in the 
future must take this into account. The study, under medical 
supervision, of the physiological and psychological develop- 
ment of the child might to advantage be introduced into our 
Normal School and its gradual evolution include all our 
schools. 

The question may fairly be asked, Can Hawaii with its 
limited funds afford a medical inspection system? The real 
question is. Can she afford to be without it? Education today 
has become more and more of a science and teaching more 
and more of a profession. The taxpayers have a right to 
expect value received for money expended for educational pur- 
poses. If by such a system we can assure more regular attend- 
ance at school, thus giving the child the instruction we are 
paying for, even when he is absent, if by careful watching 
we can ''nip in the bud" epidemics of all kinds, thus reducing 
quarantine and fumigation expenses, if by lessening the tend- 
ency to crime we can reduce expenditures for policing, the 
amounts expended will be trifling as compared with the 
savings. 

The average cost of instruction per capita in this Territory 
for the last four years was $23.30, or per day, counting five 
school days to a week, for the thirty-eight weeks, 16^ cents. 
For this 16^2 cents we expect each child to receive a certain 
amount of instruction. Whenever a child is absent from 
school, the Territory spends this money and for it gets no 
return. If the 4,605 eye treatments at the Dispensary the last 
year, and one-half of the other treatments, or 530, represent 
the loss of a school day by the child, this means an expendi- 
ture on the part of the Territory of $8,472.72 for instruction 
which was not given. In January, 1907, the Hanapepe School, 
with an enrollment of 305, lost 30 school days owing to an 
epidemic. In March, the Makaweli School, with an enroll- 



6 

ment of 109, lost 29 days, and the Waimea School, with an 
enrollment of 265, thirty-two days, and in February, 1908, with 
an enrollment of 316, ten days. Thus, 995 children were forced 
out of school and loi school days were lost. The Territory 
paid $3,944.65 for which it received no return. During this 
time we paid over a thousand dollars in salaries to teachers 
who, through no fault of their own, were unable to do the 
work for which they were paid. This represents but three 
schools and for but a limited period of time. 

Our uniform course of instruction is based on the work a 
normal child can do. If, because of improper seating, defec- 
tive vision, imperfect hearing, bad condition of nose, throat, 
teeth, spine, other organic or chronic troubles, a child is unable 
to do the required work and is compelled to take over one or 
two years' work, the Territory pays twice or three times the 
usual amount for the year's work of that child. We have no 
special schools for the blind, deaf or backward and it there- 
fore behooves us to render our children as physically fit as 
possible to do the work in the schools we have. Were accu- 
rate figures obtainable of all children absent or incapacitated 
for regular school work, I believe it could be proven that the 
Territory is spending each year vastly more money for instruc- 
tion which it is not receiving, than a thorough inspection 
would cost. It is estimated that from 50 to 75% of parents 
notified of defects in their children gladly afiFord means of 
relief. Our truancy and health laws could doubtless handle 
nearly all other cases. 

At the last session of the Territorial Legislature the follow- 
ing bill was introduced : 

''Section i. The Department of Public Instruction is here- 
by authorized to appoint a Medical Inspector to hold office 
during its pleasure and to receive such compensation as the 
Department may fix. Such appointee shall be a physician 
duly licensed to practice medicine and surgery within the Ter- 
ritory. 

"Section 2. It shall be the duty of the Medical Inspector, 
under the direction of the Department to visit at least once 
in every two years each school in the Territory, to examine 
the children in such schools for the purpose of determining 
their health and physical condition, to reduce the results of 
such examination to writing furnishing each child examined 
with one copy, filing one copy with the teacher in charge of 
such school and filing one copy with the Department. He 
shall also advise with and instruct the teachers regarding mat- 
ters of hygiene and sanitation and as to the proper method 
of treatment for minor injuries, and when directed by the 
Department, shall address teachers' meetings on the same or 



similar subjects. He shall perform such other duties as the 
Department may require of him. 

"Section 3. No Medical Inspector appointed under the pro- 
visions of this Act shall, while holding such office, engage in 
private practice of his profession, nor shall anything in this 
act contained authorize or empower such Inspector to pre- 
scribe for and treat generally any public school children." 

This bill failed to pass and I am inclined to believe for the 
reason that its provisions were not clearly understood. Some- 
what careful investigation has convinced me that a much more 
thorough system should be outlined ; that a number of medical 
inspectors and nurses should be provided and that the system 
should be operated under the joint supervision of the Depart- 
ment of Public Instruction and the Territorial Board of 
Health. 

The time is ripe, the conditions unusually favorable, and 
the amount of money needed insignificant to make this Terri- 
tory a leader in its educational work. Hawaii claims the most 
beautiful country in the world ; the finest climate ; the most 
scientific development of its sugar industry ; leadership in 
many lines. May it not in the near future rightfully claim 
the most advanced educational system? 



THE NECESSITY FOR THE EXAMINATION OF 

THE EYES, NOSE, EARS AND THROAT 

OF SCHOOL CHILDREN. 



Wm. C. Rogers, M. D., 
Specialist. 

For a number of years, medical men have recognized the 
necessity of having the physical condition of school children, 
the best, not only to prevent contagion in the schools, but for 
what is more important, the most rapid advance possible of the 
pupils themselves in the various branches of study alloted to 
them. 

In the first place I want to call attention to the importance 
not only of good eyesight but also to the importance of easy 
eyesight, in the child who is trying to acquire an education. 
A great many children have good and apparently perfect eye- 
sight, but on account of eyestrain their faculties are seriously 
interfered with. Take, for instance, a child with a very small 
refractive error, while it may be able by a very thorough test, 
to see both distant and near objects clearly, yet eyestrain and 
reflex symptoms, from a small error, are much more pro- 
nounced in such a case than in one whose error is more pro- 
nounced and whose sight may be so defective that it is easily 
apparent. This may be explained by the fact that in the case 
of the small error the eyes are constantly trying to overcome 
this and attain normal vision, while in the case of the greater 
defect the eyes cannot and therefore do not try to overcome 
such defect. Perhaps the most common symptoms of eye- 
strain are frontal headache, smarting and itching irritation of 
the eyes and sometimes pain in the eyes. The way in which 
this affects a student's mental concentration is as follows : 
After a greater or less period of using the eyes the student 
begins to be aware of this irritation of the eyes, this in turn 
detracts his mind from his studies so he has to be continually 
calling it back to the work in hand. This constant effort soon 
produces a mental exhaustion with the symptoms of headache 
and drowsiness. In this state it is difficult for the pupil to 
continue his studies, or if he does, it is impossible for him to 
learn his lessons properly. Consequently he is pronounced 
lazy or stupid and a poor student, while if this defect had 
been corrected he might easily make a good average in his 
classes. 

In the second place we will consider the effect poor hearing 
would have on the student. It is easy to understand how a 
child whose hearing of one or both ears is defective would be 



9 

handicapped in the class room. His inability to hear what is 
said creates a misunderstanding and probably calls down 
punishment that is not merited. While his power of acquir- 
ing knowledge out of books may not be interfered with, still 
he is at a disadvantage in the class by not being rtble to hear. 

In the third place we will consider the effect of nose and 
throat troubles on school children. Probably every one has 
seen cases of children who have frequent attacks of what 
may be called cold or bronchitis or indigestion according to 
what symptoms predominate at the time. These cases are 
often a sejJtic infection from the tonsils. They have the symp- 
toms of fever, stupor, difficult and noisy breathing and prob- 
ably digestive troubles. The tonsils are enlarged and when 
they are removed are found to be filled with highly poisonous 
and purulent material. This has produced infection and has 
been the cause of the frequent attacks of illness. Children 
who have enlarged tonsils almost always have adenoids 
obstructing the posterior nasal passages preventing the child 
from breathing properly through the nose, thus causing what 
are ordinarily called "mouth breathers." The inability to 
breath properly through the nose produces congestion about 
the nasal passages, eustachian tubes to the ears, and the 
numerous cells between the nose and the brain. Thus the 
brain is often affected so that the mental faculties are not only 
dulled, but the child becomes indolent and wayward and may 
also become weak-minded. 

In the above it has been shown that these various defects 
of the eyes, ears, nose and throat not only have a tendency to 
produce dull students but also degenerates and criminals. As 
a matter of fact it has been found that a large percentage of 
children sent to reform schools, houses of correction and other 
institutions of that character have some physical defect of 
these most vital organs, that might, if taken in time, have 
changed the character of the case entirely. This may be ex- 
plained by the fact, that study having been made difficult by 
some physical defect, the pupil looses ambition and rather 
than face his teacher with illy-prepared lessons, prefers tru- 
ancy and thus progresses step by step into degeneracy and 
vicious habits. 

The remedy might be divided as follows : 

1st. Detection, treatment and prevention of contagious dis- 
eases. 

2nd. Detection and treatm.ent of eye, ear, nose and throat 
defects. 

3rd. Separating those with incurable mental or phvsical 
defects into classes where they will receive more intelligent 
instruction and not obstruct others who can advance more 
rapidly. 



10 



CARE OF CHILDREN'S TEETH. 



J. M. Whitney, M. D., D. D. S., 
Ex-President Dental Society of Hawaii. 

Diseases of the teeth have always been regarded as a neces- 
sary evil, from which none may hope to escape ; one' of the 
minor ills of life, ''regrettable but practically unavoidable." 
When such a view is generally accepted, it is difficult to 
awaken public sentiment to a realization of its true character, 
and the need and possibility of relief. For this reason it is a 
hopeful sign of the times, that in many quarters earnest efforts 
are being made to instruct parents and teachers concerning 
the gravity of the results attendant upon dental disease, and 
to provide for the poor and especially the children of the public 
schools such free dental supervision and treatment as they 
may require. 

Dr. Paul Gardiner White of Boston, in a recently published 
pamphlet, makes the astonishing statement that "three-fourths 
of the highly intelligent well educated people look upon the 
teeth as able to take care of themselves even in adult life, and 
that they receive with surprise and incredulity the suggestion 
that the teeth of children should be carefully cleaned and 
attended to." 

The famous Prof. William Osier of Oxford, England, says, 
truthfully if rather crudely : ''All children should be taught to 
clean their teeth ; all children should have the mouth and teeth 
inspected, and connected with every school there should be 
a dental surgeon and he should make a routine inspection of 
these children and report upon them, and should their teeth be 
bad or dirty they should be told not to come to school until 
their teeth are attended to, for a child with bad teeth is a dan- 
ger in a school." 

First : In considering the question of danger to the school 
we may note that a mouth and teeth uncared for become the 
best possible place for the extensive and rapid growth of bac- 
teria, from thirty to a hundred different species of which may 
find lodgment therein. As these are thrown out at every 
breath, and in many other ways, a school, however well venti- 
lated shortly becomes laden with the health-destroying exhala- 
tions, so that teachers and scholars come to have a sense of 
lassitude which prevents them from doing their best work, 
and with the less vigorous, compels them to lose time by fre- 



11 

qiient days at home. This has been clearly proven by experi- 
ments in New York City, where careful dental inspection has 
been given to a school, in which the saving to pupils and 
teachers has more than paid for the services of the dentist. 

Second : As the vitality of the individual is lowered when 
mouth and teeth have been neglected, it has been noted by 
careful observers, that when any contagion or epidemic in- 
vades a school, it is these unfortunate ones who are first to be 
overtaken and the last to recover. Similar observations made 
by an eminent foreign physician called forth the statement 
that with mouth and teeth properly cared for little danger 
was to be apprehended from contagious or epidemic diseases. 

Third : The ordinary school room contains four volumes of 
carbon dioxide to every loo volumes of air. Suppose that 
among the 40 to 60 children, a half or even a fourth add to the 
ordinary impurities of each exhalation the poisonous gases of 
food debris contained in cavities of decay, corrupt breath, 
caused by inflammation of gums from accumulation of tartar 
and pus from alveolar abcess, and the oral impurities combine 
with the air breathed by all the occupants of the room, you 
have serious conditions that no community which is looking 
for the best interests of its children can allow to remain. 

Fourth : There is nothing in the whole range of human 
possession so precious to a man as his health, therefore health 
is first wealth. No people can rest secure which has not regard 
for the sanitary essentials by which health is safe-guarded. 
It is recognized by up-to-date physicians as well as dentists 
that sound teeth are essential to the health of the human 
organism in general. Is it not the work of the schools to 
teach the best living on all lines? There can be no strong-er 
argument in favor of the thorough examination of the mouth 
and teeth of school children than the educational benefits to 
the parents and the whole community by calling attention to 
the fact that the school is the logical place to begin the study 
of the physical well being of mankind, a feature of education 
which is only just beginning to command the attention it 
deserves. 

So recently as October, 1902, Strassburg, Germany, was the 
first city of note to establish in the public schools a dental 
clinic under Dr. Ernest Jessen. 

In December of the same year Darmstadt established a simi- 
lar clinic, the expense in each case being municipal. So satis- 
factory have been the results of this compulsory care of the 
teeth of school children in these cities, that at the present time 
more than thirty other cities in Germany have followed the 
same plan, which is being extended to other continental cities. 
In England much is being done by the School Dentists* 



12 

Society, through the systematic inspection of the teeth of 
school children. 

New York seems to be the only American city in which free 
dental services for public school children has been provided 
by the school authorities. In several other American cities, 
notably in Boston, Rochester, Cleveland, Milton, Pa., and 
New London, Conn., free dental clinics, not directly connected 
with the public schools have been provided. Medical inspec- 
tion, considering the general health of the pupils, the sanitary 
conditions, the water used and similar items have long been 
provided, in all the large cities of Europe and America. But 
a large and most important field of investigation and care has 
been generally overlooked, one in which only a skilled dentist 
can serve. 

Owing to our peculiar racial and sanitary condition it may 
be said that there can hardly be a place where such preventive 
measures as are here indicated are more called for than in our 
public schools. These suggestions are therefore presented 
with the hope that some measures may be adopted by the 
proper authorities, not only to impress upon parents and teach- 
ers the importance and need of greater care of the mouth and 
teeth of their children, but to impress upon the child himself 
such lessons of care and cleanliness that when he is older, he 
will not depart from them. 



13 



TUBERCULOSIS AMONG SCHOOL CHILDREN IN 

HONOLULU. 



James R. Judd, M. D., 

Member Board Medical Examiners, Ex-Member Board of Health, 
Surgeon Queen's Hospital. 

It is estimated that the Great White Plague claims annually 
5,000,000 victims and in the United States alone more than 
150,000 deaths a year at the average age of 35 are due to this 
dread disease. 

The mortality in Honolulu from tuberculosis is heavy. For 
the years 1903 to 1907 inclusive there were 759 deaths from 
this disease divided according to nationality as folloAvs : 
Chinese, 155; Japanese, 132; Hawaiian, 346; other nationali- 
ties, 126. This is an average of 167 deaths per 1000 or 380 
deaths per 100,000 population. The United States census re- 
port for the year 1900 records 109 deaths from consumption 
per 1000 deaths or 204 per 100,000 population. A comparison 
of the above figures shows an excessive mortality for Ho- 
nolulu. 

During childhood and youth everything possible must be 
done in the schools to favor the development of a sound 
physique. 

A large playground is essential. 

In some German cities the shower-bath is a compulsory part 
of the school curriculum, the children going to their baths in 
relays during school hours. Shower baths do more than im- 
prove the appearance and cleanse the body. They are an excel- 
lent stimulant to the nervous system and give tone and vigor 
to the muscles. 

The proper lunch for a school child is a problem. Some 
families are too poor or too shiftless to provide a wholesome 
lunch. A lunch at home after school hours would be better 
than the sodden cakes, dust-covered candy, peanuts and soda 
water purchased from street vendors. 

In an open-air country like Hawaii the problem of ventila- 
tion of the school room is readily and successfully met, and in 
our up-to-date school houses the requirements of cleanliness of 
the school room are obtained. 

In some places on the Mainland there has been inaugurated 
a ''Health Day." One entire day of the school year is given 
up to instruction in health as it affects the social and industrial 
position of the individual. 

In considering the problem of tuberculosis in its relation 



14 

to the schools, effort is not especially needed towards saving 
school children from this disease as comparatively few con- 
tract consumption at the school age of 6 to 12 years, but in the 
schools there is opportunity for using one of the most, if not 
the most powerful factor we have towards fighting tubercu- 
losis, that is the power of education. Every case of consump- 
tion is contracted from some consumptive, either directly or 
indirectly, and if every consumptive could be taught how to 
render himself harmless to his fellow-men, there would soon 
be a marked decrease in the death roll. 

Teachers should have a sufficient knowledge of the subject 
to be able to impart an understanding of the essentials of the 
disease to the older children. Instruction should be given as 
to the cause of the disease which could be explained in such 
simple language as to be readily understood by the pupils. 
The method of infection through the dust, contaminated by the 
sputum of consumptives, should be set forth. Particular atten- 
tion should be given about spitting, so that a child might 
know that it is as repulsive to rid himself of his sputum on the 
floor as of his other excreta. Some children may acquire this 
knowledge at home, but most children will not learn these 
things unless at school. 

Dr. Knoffs' excellent rules for school children are as fol- 
lows : Do not spit except in a spitoon, on a piece of cloth, or a 
handkerchief used for that purpose alone. Never spit on a 
slate, floor, sidewalk, or playground. Do not wet your fingers 
in your mouth when turning the leaves of books. 

Do not put pencils in your mouth or wet them with your 
lips. 

Do not hold money in your mouth. 

Do not swap apple-cores, candy, chewing gum, whistles or 
anything that is put into the mouth. 

Never cough in a person's face. Turn your face to one side 
and hold a handkerchief before your mouth. 

Medical inspection of schools would be of great value in 
detecting consumption in the early stages and also in detecting 
conditions predisposing towards consumption. So far as tuber- 
culosis is concerned, the medical inspector with the coopera- 
tion of the watchful teacher would detect such conditions as 
mouth-breathing, swelling of the glands of the neck, persistent 
coughs, catarrhs, and running- ears ; pale or feverish, easily 
fatigued, nervous or fretful children should be carefully exam- 
ined. Tuberculosis in children manifests itself in bones and 
joints rather than in the lungs. Joints that are tender and 
painful on pressure could be detected early. Affections of the 
vertebral column could be observed before a hopeless case of 
Potts disease had developed. 



15 

The struggle against the Great White Plague is engaging 
the attention of the civilized world as a world problem. Let 
us hope that the opportunity to combat tuberculosis through 
the agency of the school children may not be neglected. 



16 

THE QUARANTINE STANDPOINT. 



L. E. CoFER, M. D., 
Passed Assistant Surgeon, Chief Quarantine Officer Territory of 

Hawaii. 

In reply to your request for a letter bearing upon the subject 
of the medical inspection of schools with the view of making 
an early discovery of contagious diseases possibly present 
amongst pupils, I have to say that no other sanitary prophy- 
lactic measure is as important in municipal quarantine work. 

With parents who habitually pay attention to medical as 
well as to the other needs of their children, medical inspection 
might possibly be regarded as superfluous, but even such 
parents are powerless to protect their children /.gainst infec- 
tion from contagious diseases. In other words it is not so 
much the gross as the hidden danger which justifies the con- 
stant medical inspection of school children. 

In Philadelphia during the year 1904, 3/9% of the school 
population were excluded for diphtheria ; in 1905 as a result 
of a more careful medical examination 4/7% were excluded. 
In 1906, the ratio increased to i 5/8%. 

The scarlet fever exclusion ratio during the same period of 
three years ranged from 4/7% in 1904 to i 1/22.% in 1906. 

The measles ratio ranged from i 5/14% in 1904 to 12% in 
1906. 

The chickenpox ratio ranged from i 2/3% to 2 1/3% dur- 
mg the same period. 
• In other diseases the ratio showed a similar increase just in 
proportion as the functions of medical inspection were ela- 
borated. Speaking from the standpoint of a quarantine officer, 
a medical inspection of schools furnishes an accurate index of 
the health status of a city, both by districts and by houses 
individually. In view of the contagious diseases to which 
Hawaii is constantly exposed, I can think of no place wherein 
a regular medical inspection of schools is more vitally 
necessary. 



17 
MASSACHUSETTS LAWS. 



ACTS OF 1906, CHAPTER 502. 

An Act Relative to the Appointment of School Physicians. 

Section i. The school committee of every city and town 
in the Commonwealth shall appoint one or more school physi- 
cians, shall assign one to each public school within its city or 
town, and shall provide them with all proper facilities for the 
performance of their duties as prescribed in this act ; provided, 
however, that in cities wherein the board of health is already 
maintaining or shall hereafter maintain substantially such 
medical inspection as this act requires, the board of health 
shall appoint and assign the school physician. 

Section 2. Every school physician shall make a prompt 
examination and diagnosis of all children referred to him as 
hereinafter provided, and such further examination of teachers, 
janitors and school buildings as in his opinion the protection 
of the health of the pupils may require. 

Section 3. The school committee shall cause to be referred 
to a school physician for examination and diagnosis every 
child returning to school without a certificate from the board 
of health after absence on account of illness or from unknown 
cause; and every child in the schools under its jurisdiction 
who shows signs of being in ill health or of suilering from 
infectious or contagious disease, unless he is at once excluded 
from school by the teacher ; except that in the case of schools 
in remote and isolated situations the school committee may 
make such other arrangements as may best carry out the pur- 
poses of this act. 

Section 4. The school committee shall cause notice of the 
disease or defects, if any, from which any child is found to be 
suffering to be sent to his parent or guardian. Whenever a 
child shows symptoms of smallpox, scarlet fever, measles, 
chicken-pox, tuberculosis, diphtheria or influenza, tonsilitis, 
whooping cough, mumps, scabies or trachoma, he shall be 
sent home immediately, or as soon as safe and proper con- 
veyance can be found, and the board of health shall at once 
be notified. 

Section 5. The school committee of every city and town 
shall cause every child in the public schools to be separatelv 
and carefully tested and examined at least once in every school 



18 

year to ascertain whether he is suffering from defective sight 
or hearing or from any other disability or defect tending to 
prevent his receiving the full benefit of his school work, or 
requiring a modification of the school work in order to pre- 
vent injury to the child or to secure the best educational 
results. The tests of sight and hearing shall be made by 
teachers. The committee shall cause notice of any defect or 
disability requiring treatment to be sent to the parent or 
guardian of the child, and shall require a physical record of 
each child to be kept in such form as the state board of educa- 
tion shall prescribe. 

Section 6. The state board of health shall prescribe the 
directions for tests of sight and hearing; and the state board of 
education shall, after consultation with the state board of 
health, prescribe and furnish to school committees suitable 
rules of instruction, test-cards, blanks, record books and other 
useful appliances for carrying out the purposes of this act, 
and shall provide for pupils in the normal schools instruction 
and practice in the best methods of testing the sight and hear- 
ing of children. The state board of education may expend dur- 
ing the year nineteen hundred and six a sum not greater than 
fifteen hundred dollars, and annually thereafter a sum not 
greater than five hundred dollars for the purpose of supplying 
the material required by this act. 

(Amended Sec. 6, Chapter 44, Revised Laws.) 

Section 6. A child who has not been vaccinated shall not 
be admitted to a public school except upon presentation of a 
certificate signed by a regular practising physician that he is 
not a fit subject for vaccination. A child who is a member 
of a household in which a person is ill with smallpox, diphthe- 
ria, scarlet fever, measles, or any other infectious or contagious 
disease, or of a household exposed to such contagion from 
another household as aforesaid, shall not attend any public 
school during such illness until the teacher of the school has 
been furnished with a certificate from the board of health of 
the city or town, or from the attending physician of such per- 
son, stating that danger of conveying such disease by such 
child has passed. 



19 
NEW YORK CITY SCHOOL MEDICAL INSPECTION. 



OBJECTS. 



1. Repeated and systematic inspection and examination of 
school children to determine the presence of infectious or con- 
tagious disease. 

2. Exclusion from school attendance of all children affected 
with acute contagious disease. 

3. Subsequent control of the case, with isolation of the 
patient and disinfection of the living apartments after termina- 
tion of the illness. 

4. Control and treatment of minor contagious affections, 
permitting the child to remain in attendance at school. 

5. Information of unreported cases of contagious disease, 
occurring in school children at their homes. 

6. Exclusion from school attendance of those children in 
whose families there exists a contagious disease. 

7. Complete physical examination of each school child, for 
the purpose of determining the existence of non-contagious 
affections, and advising treatment of same. 

FORCE. 

1. Assistant Chief Medical Inspector, in charge of work. 

2. Corps of Medical Inspectors, all of whom are physicians. 

3. Supervising Nurse, in direct charge of the nurses. 

4. Corps of Trained Nurses. 

WORKING PLAN OF THE SYSTEM. 

Duties of Medical Inspectors. 

Each Inspector is assigned to duty in a group of schools. 

I. Morning Inspection. 

Inspector visits each school in his charge before ten o'clock 
each morning, and examines in a room set apart for this pur- 
pose, the following : 

(a) All children isolated by the teachers as suspected cases 
of contagious diseases. 

(b) All children who have been absent from school. 

(c) Children returning after previous exclusion. 

(d) Children previously ordered under treatment. 

(e) Children referred by the school nurse for diagnosis. 



(f) All affected children showing no evidence of treatment. 
Cases to be Excluded. 

(a) Children showing signs or symptoms of smallpox, 
diphtheria, scarlet fever, measles, chicken-pox, whooping 
cough or mumps. 

Cultures are taken in all cases of sore throat to determine 
the presence of the diphtheria bacillus. 

Cases of smallpox, scarlet fever and measles are reported, 
by telephone, to the Central Office, so that a diagnostician 
may at once visit the case, confirm the diagnosis and order 
isolation. In these cases a postal card is sent from the Divi- 
sion of Contagious Diseases to the principal of the school in- 
forming him, or her, of the presence of contagious disease, 
with instructions that no member of the family be allowed to 
attend school until the termination of the case. 

(b) Cases of pediculosis, with live pediculi. 

(c) Children affected with contagious eye and skin dis- 
eases, and dormant pediculosis, who have persistently refused 
to undergo treatment. 

Cases to be Referred to Their Own Physician, a Dispensary 
or to the School Nurses for Treatment. 

(a) Acute conjunctivitis. 

(b) Pediculosis. 

(c) Skin Diseases, including ringworm of scalp, face or 
body, scabies, favus, impetigo and molluscum contagiosum. 

These children are re-examined the following day and 
allowed to attend school as long as treatment is continued. 
Children affected with trachoma are referred to their own 
physician or to a dispensary for treatment, and are allowed 
to attend school as long as evidence of treatment can be shown. 



LIBRARY OF CONGRESS [ 




